Human Factors Analysis 4 Health Care - ECRI Rebold Group De… · Chest x-ray obtained and revealed...

©2015 ECRI INSTITUTE

Human Factors Analysis 4 Health Care

Group Demonstration

October 15, 2015

©2015 ECRI INSTITUTE©2015 ECRI INSTITUTE

Directions

©2015 ECRI INSTITUTE3

HFACS4HC Taxonomy

Unsafe Acts

Errors Violations

Judgement and Decision-

making Errors

Skill-based Errors

Misperception errors

Routine (“Bending” the

rules)

Exceptional (Breaking the

rules)

CATEGORY

SUBCATEGORYSUBCATEGORY

NANOCODES


Worksheet #1

HFACS4HC Taxonomy Worksheet■ Use this to determine

HFs.■ Use the checkboxes


Worksheet #2

Review sections 1, 2, 3

Complete sections 4, 5, 6.

Use to report out your findings


Worksheet #2

Review the following pre-filled sections■ 1. Event Description■ 2. Timeline■ 3. Interviews

Complete the following sections■ 4. HFACS4HC Findings■ 5. Summarize Nanocodes■ 6. Determine Action Plans

There are additional and optional sections. A template is included on the website.

©2015 ECRI INSTITUTE©2015 ECRI INSTITUTE

Sample Case Demonstration


1. Event Description A 55-year-old man with a history of poorly controlled diabetes mellitus,

pancreatic insufficiency, and alcohol and cocaine abuse was found unconscious by his neighbors. The patient had last been seen 2 days prior and complained of dizziness, thirst, and nausea.

Emergency medical services found him unresponsive, with a Glasgow Coma Scale score of 3. He was intubated in the field.

Upon arrival in the emergency department (ED), his pH was less than 6.8, carbon dioxide 37 mm Hg, oxygen 80 mm Hg, potassium 7.8 mEq/L, glucose 1400 mg/dL, lactate 11.2 mg/dL, and anion gap 42 mEq/L. A right internal jugular line was placed for access. The resident who placed the line was relatively experienced in line placement but was unable to confirm placement with ultrasound. Instead he used manometry, which was not a part of the normal ED routine for line placement.


1. Event Description (continued) He ultimately chose to pull the line. Just then, another trauma patient

arrived, and the supervising attending physician left the room. The resident opened a second line insertion kit and restarted the process. Ultrasound was used to confirm correct placement..

Upon flushing the line, it was noted that one of the ports was not working. The patient soon went into atrial tachycardia, which broke with adenosine. A chest radiograph was not obtained until later, after the patient went into ventricular fibrillation in the intensive care unit. When the chest radiograph was finally completed, a retained wire was noted in the pulmonary artery. The interventional radiology team was consulted for wire removal. The retained wire likely caused a cardiac arrest, which required shocks, chest compressions, and cooling. After guidewire removal, the patient had no further episodes of arrhythmias, but experienced several other serious complications during a prolonged and stormy hospitalization


2. Timeline2.TimelineDate/Day/Time Event DescriptionPatient’s home Emergency crew intubates in the fieldER Arrives in ERER ER lab work pH was less than 6.8, carbon dioxide 37 mm Hg, oxygen 80 mm Hg,

potassium 7.8 mEq/L, glucose 1400 mg/dL, lactate 11.2 mg/dL, and anion gap 42 mEq/L.

ER Right internal jugular line was placedER Unable to confirm placement with ultrasound. Manometry used. Line removedER Supervising attending physician left the roomER The resident restarted the process. Ultrasound was used to confirm correct

placement. Upon flushing the line, it was noted that one of the ports was not working

ER Patient soon went into atrial tachycardia, which broke with adenosineICU Patient to intensive care. Experienced ventricular fibrillationICU Chest x-ray obtained and revealed a retained wire was in the pulmonary artery. Radiology The interventional radiology team was consulted for wire removal. The retained

wire likely caused a cardiac arrest, which required shocks, chest compressions, and cooling. After guidewire removal, the patient had no further episodes of arrhythmias, but experienced several other serious complications during a prolonged and stormy hospitalization


3. Interviews

These usually have already been completed when the event was investigated. They will add to the facts.

You may want to add interviews based on findings.

3.Interviews

Date Title Name Notes

Attending Dr. Charge

Resident Dr. Joe

Other staff in room Nurse Mary


Determine the HFACS4HC Nanocodes

Worksheet #1

Use this to determine HFs.


4. HFACS4HC FindingsRecorder notes Nanocodes on Worksheet #2

4.HFACS4HC Findings: HFACS Category Sub Category Nano Codes Why? Unsafe Acts � Preconditions

for Unsafe Acts

� Supervision � Organization

al Influences

Error: skill based Error

Poor technique Did not use ultrasound to confirm placement of first jugular line

Unsafe Acts � Preconditions

for Unsafe Acts


al Influences

Judgment and Decision Making

Selected incorrect procedure Used manometry instead of ultrasound

Unsafe Acts � Preconditions

for Unsafe Acts


al Influences

Violation: Routine (Bending the Rules)

Violation of policy/procedure/standard of care Failed to make sure equip could be properly used Disabled guars, warning systems or safety devices

Used manometry instead of ultrasound

� Unsafe Acts Preconditions

for Unsafe Acts


al Influences

Environmental Factors: Technological Environment

inadequate/defective warnings/alarms

Use of manometry

� Unsafe Acts Preconditions

for Unsafe Acts


al Influences Unsafe Acts

Personnel Factors: Communication/Coordination/ Planning

Failed to use all available resources

Did not use ultrasound


4. HFACS4HC Findings (continued)Recorder notes Nanocodes on Worksheet #2

� Unsafe Acts � Preconditions

for Unsafe Acts

Supervision � Organization


Inadequate Supervision

Failed to provide adequate oversight Failed to identify at risk caregiver Failed to communicate policies Failed to provide adequate mentoring/coaching/instruction

Supervising attending present during first insertion yet does not require use of ultrasound


for Unsafe Acts



Failure to address Known Problem

Failed to report unsafe tendencies (allowing people to slide when they are wrong) Failed to initiate corrective action (correct known problem) Failed to ensure problem was corrected

Supervising attending leaves room despite knowing resident is planning to do a second insertion


for Unsafe Acts



Supervisory Violations

Failed to enforce policies/procedures/requirements Authorized hazardous operation: Allowing unknown hazardous operations to continue for whatever reason

Supervising attending allows use of manometry instead of ultrasound and leaves room despite knowing resident is planning to do a second insertion


for Unsafe Acts

� Supervision Organization


Organizational Climate

Culture that does not condemn hazardous and/or unethical behavior

No member of team spoke up about lack of use of ultrasound


5. Summary of NanocodesSum the nanocodes, subcategories, categories


6. Actions - Create an Action Plan


Questions?

Thank You


Human Factors Analysis 4 Health Care

Break Out Work Groups

October 15, 2015


PurposePractice applying HFACS4HC to a case

study.Develop a preliminary action plan.Discuss how you will use HFACS4HC in

your organization.

Remember, there are no wrong answers!


Instructions

Assemble in your assigned group The ECRI Facilitator will lead you to your room Designate members of the group for the following roles:

■ A recorder■ A presenter■ A timekeeper

Use meeting time as follows:■ 15 minutes-review case study and timeline (Sections 1, 2, 3)■ 40 minutes-apply nanocodes and sum them into categories

(Sections 4 and 5)■ 20 minutes-develop actions for nanocodes (Section 6) and

discuss how you will use HFACS4HC in your organization

20


Instructions Only apply HFACS4HC when the information is stated, do

not make assumptions Use index cards to record questions from the group to the

speakers panel. On return to the full meeting, report out:

■ Section 4. What HFs nanocodes did you identify? Why? ■ Section 5. Which Categories were your top 2? ■ Section 6. What actions did you plan? ■ Your thoughts/suggestions about how you will use HFACS4HC in

your organizations?

After the reports from the break out groups, the speakers panel will assemble for Q&A. Use index cards

21


Worksheet #1

HFACS4HC Taxonomy Worksheet■ Use this to determine

HFs.■ Use the checkboxes


Worksheet #2

Case Summary Complete sections

4, 5, 6. Use to report out

your findings


Your breakout group color is indicated on your name badge


Finish Breakout at 3:45 PMBreak 3:45 – 4:00 PMPlease return promptly at: 4:00 PM


Please follow your ECRI facilitator to your classroom

Human Factors Analysis 4 Health Care - ECRI Rebold Group De… · Chest x-ray obtained and revealed...

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